HESI LPN
Medical Surgical Assignment Exam HESI
1. What is the main characteristic of cystic fibrosis?
- A. Multiple upper respiratory infections
- B. An underproduction of exocrine glands
- C. Excessive, thick mucus
- D. An overproduction of thin mucus
Correct answer: C
Rationale: The main characteristic of cystic fibrosis is the production of excessive, thick mucus. This thick mucus leads to blockages in the airways, digestive system, and other organs. Choice A is incorrect because while individuals with cystic fibrosis are more prone to respiratory infections, the main characteristic is the mucus production. Choice B is incorrect as cystic fibrosis is characterized by the overproduction, not underproduction, of exocrine glands. Choice D is also incorrect as the mucus produced in cystic fibrosis is thick, not thin.
2. Following surgical repair of a cleft palate, what should be used to prevent injury to the suture line?
- A. Straw
- B. Spoon
- C. Syringe
- D. Cup
Correct answer: D
Rationale: Following surgical repair of a cleft palate, a cup should be used to prevent injury to the suture line. Utensils such as straws, spoons, droppers, and syringes should be avoided as they can cause trauma to the surgical site. Using a cup reduces the risk of disrupting the sutures and promotes proper healing.
3. Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia. Which finding should the nurse document in the EMR as a therapeutic response to the lidocaine infusion?
- A. Stabilization of BP ranges
- B. Cessation of chest pain
- C. Reduced heart rate
- D. Decreased frequency of episodes of VT
Correct answer: D
Rationale: The correct answer is D. Decreased frequency of ventricular tachycardia (VT) episodes indicates that the lidocaine infusion is effectively managing the ventricular tachycardia. Stabilization of BP ranges (choice A) may not directly correlate with the therapeutic response to lidocaine for VT. Cessation of chest pain (choice B) may indicate pain relief but does not specifically address the effectiveness of lidocaine for VT. Reduced heart rate (choice C) is not a direct indicator of the response to lidocaine for managing VT.
4. Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease?
- A. Avoid cold temperatures completely.
- B. Take medications only during flare-ups.
- C. Wear gloves when removing packages from the freezer.
- D. Limit physical activity to avoid stress.
Correct answer: C
Rationale: The correct instruction for a client with Raynaud's disease is to wear gloves when handling cold items to prevent vasospasm. Raynaud's disease is characterized by vasospasm in response to cold or stress, leading to reduced blood flow to extremities. Wearing gloves when removing packages from the freezer helps minimize exposure to cold temperatures and can prevent triggering vasospasms. Choices A, B, and D are incorrect. Avoiding cold temperatures completely is impractical and may not always be possible. Taking medications only during flare-ups does not address prevention strategies, and limiting physical activity to avoid stress is not a primary intervention for Raynaud's disease.
5. The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?
- A. Notify the healthcare provider of the findings.
- B. Ensure that the IV is infusing at the prescribed rate.
- C. Listen to lung sounds.
- D. Check under his back for evidence of bleeding.
Correct answer: D
Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.
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